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�fllection Report Number <br /> Waste Tire & Inspection Rep � <br /> CalRecycle State of California I 1 - 1226210 <br /> CalRecycle181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK P E N <br /> Part A-Surve _ - - - <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ,� T ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �cy� �,, 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name /�- Inspected By Inspector <br /> r _ <br /> Physical Address I -3 r'f 0 47/ F <br /> Inspection Date / / `Z. / <br /> Time In Time Out <br /> Title O AM O AM <br /> Business Rep ® 3 ® PM © `l ® PM <br /> ®lit/Yt-Q� Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) j r <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer. 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®in Compliance-No Violations o <br /> 0 0 Other:§ i <br /> Comments .arc i r7> ez4 C am az '4""—�A lei w kn <br /> Inspection Form Included: 0 M Lib r,06 y� <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number 'Inspector's Signature Phone Number <br /> • 62081 <br /> INSTRUCTIONS ON BACK <br /> [Correct, Incorrect: EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />